UNIVERSITY OF CALIFORNIA, IRVINE



UNIVERSITY OF CALIFORNIA, IRVINE

REQUEST TO USE UNIVERSITY EQUIPMENT IN STEM CELL RESEARCH

Federal restrictions prohibit the use of federal resources to support research with embryonic stem cells that are not on the NIH Human Embryonic Stem Cell Registry. This UCI form requests verification that the University has clear title to the equipment and may use the equipment for future stem cell research. If approved, a Green Tag will be affixed to the item indicating that the equipment may be used in research on cell lines that are not part of the Registry. Four conditions must be met for approval:

1) The federal contract or grant supporting the equipment purchase has been completed (including all of its competitive segments),

2) UCI Equipment Management has submitted the equipment inventory report required by the award agency and at least 120 days have elapsed from the date the report was submitted, (this condition will be an option if the equipment inventory report is not required by the award agency.)

3) The federal government has not invoked its right to transfer the equipment within the 120 day period; and

4) UCI retains title to the equipment without restriction.

Instructions:

1. Complete form and keep one copy in your department. You may attach a detailed list of additional equipment for review.

1. Send to Equipment Management 264 Public Services Building, Zot 6100.

2. The approved or disapproved form will be returned to your department/researcher with Green Tag(s) or Red Tag(s). Please affix the tag to a visible and easily accessible location on the equipment.

|Date | |Request No. |Assigned by EM |

|Researcher’s Department | |Mail code | |

|Researcher’s name | |E-mail & Phone | |

| | | | |

|Equipment Description | |UCI Property No. | |

|Manufacturer Model No. Of Equipment | |Serial No. | |Value |$ |

|Period of Use from | |to | | | |

|The equipment will be located at bldg/room# | |during the period indicated. |

| | | |

|Equipment Description | |UCI Property No. | |

|Manufacturer Model No. Of Equipment | |Serial No. | |Value |$ |

|Period of Use from | |to | | | |

|The equipment will be located at bldg/room# | |during the period indicated. |

| | | |

|Equipment Description | |UCI Property No. | |

|Manufacturer Model No. Of Equipment | |Serial No. | |Value |$ |

|Period of Use from | |to | | | |

|The equipment will be located at bldg/room# | |during the period indicated. |

|Department Chair Signature | |Date: | |

| | | | |

|Researcher Signature | |Date: | |

| | | | |

|Equipment Manager Approval | |Date: | |

| |Equipment Manager approves when all 4 conditions are met and Green Tag(s) are attached. | | |

| | | | |

|Disapproved |Condition #(s) ________ is not met and equipment may not be used for stem cell research.|Date | |

| |Red Tag(s) will be attached to the item(s). | | |

Retention: 7 years beyond expiration

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